Barriers to access to antiretroviral treatment for HIV-positive tuberculosis patients in Windhoek, Namibia

The Interface between the State and NGOs in Delivering Health Services in Zimbabwe-A Case of the MSF ART Programme

An over-reliance on donor funding for HIV/AIDS healthcare services remains a concern in Africa. This study, therefore, explores the partnership between the Zimbabwean government and an international non-governmental organisation in delivering HIV/AIDS healthcare services. An interpretivist paradigm and descriptive phenomenological design were used to elicit the opinions, perceptions, and experiences of forty purposively sampled key informants. Thematic analysis was employed using ATLAS.ti version 7.1.4 to analyse the data. The differences in terms of policies, structures, and administrative issues between the partners identified challenges in the implementation of the programme. This was demonstrated through the reversal of the gains attained in prevention, care, and treatment. This raises concerns for increased risk of defaulters, drug resistance, and deaths. Therefore, the partners in this endeavour should negotiate an aligned approach for the efficient delivery of HIV/AIDS healthcare services.

Global Outsourcing and Local Tendering Supply Chain Systems in the Public Healthcare Sector: A Cost Comparison Analysis, Namibia

OBJECTIVES

To compare supplier prices for local tendering and global outsourcing supply chain systems that are used to purchase pharmaceutical products by the Ministry of Health in Namibia and to compare the supplier prices for both systems to the international reference buyer median prices.

METHODS

This study was quantitative in design and compared local and international supplier prices for a basket of vaccines, antiretrovirals, and anti-tuberculosis (TB) drugs from 2015 to 2020. Prices were retrieved from the procurement documents obtained from the Central Medical Stores division of the Ministry of Health, Namibia. The study also compared local and international supplier prices with the international reference buyer median prices obtained from the Management Sciences for Health International Drug Price Indicator Guide (2015 edition).

RESULTS

It was found that 77% of all the pharmaceutical products in the study were more expensive when obtained from the local suppliers than from international suppliers-that is, vaccines (70%), antiretrovirals (86.6%), and anti-TB drugs (67%). More than 50% of all the pharmaceutical products had local and international supplier prices, which were higher than the international reference buyer median prices. The price differentials were found to be higher for pharmaceutical products that were newly introduced into TB and human immunodeficiency virus treatment guidelines.

CONCLUSIONS

The study has concluded that local suppliers were costlier than international suppliers for vaccines, antiretrovirals, and anti-TB drugs. The international price comparisons have shown that there is a need for improving the pricing mechanisms in Namibia to reduce the prices of several essential medicines.

Dealing with Dilemmas: Understanding the Process and Challenges of Disclosing the HIV Status of People Living with HIV/AIDS Through Gender Lens

Disclosure is governed by a host of individual, health and psychological factors that operate in and shape the decisions related to disclosure in a patient among people living with human immunodeficiency virus (PLHIV).This article studies process of disclosure, how gender affects disclosure and how it differs among PLHIV by studying their life events integrating quantitative and qualitative information from 204 respondents. Mix method approach was used to collect the data from selected male and female respondents. A total of 204 completed interviews were carried out. Bivariate and multivariate statistical techniques have been used in the study. One-third respondents reported to not have disclosed status to their partner. Female PLHIV were significantly more likely (AOR: 2.8, p < .05) to disclose their HIV status to their spouse/regular partner. Three-fifths of women were tested after they lost their husbands to AIDS or living with HIV. Around 94% women reported self-perceived stigma and 83% feared of being discriminated. Female PLHIV are approximately 3 times (p < .05) more likely to have the fear of discrimination. Findings of the study reinforce the necessity of integrating gender in every HIV prevention efforts as disclosure of HIV status may provide opportunity for early initiation of anti-retroviral therapy (ART), which may ensure adherence to ART services and suppressing the viral load.

Quality of TB care among people living with HIV: Gaps and solutions

Tuberculosis (TB) is the leading infectious cause of death among people living with HIV, causing one third of AIDS-related deaths globally. The concerning number of missing TB cases, ongoing high TB mortality, slow reduction in TB incidence, and limited uptake of TB preventive treatment among people living with HIV, all indicate the urgent need to improve quality of TB services within HIV programs. In this mini-review we discuss major gaps in quality of TB care that impede achieving prevention and treatment targets within the TB-HIV care cascades, show approaches of assessing gaps in TB service provision, and describe outcomes from innovative quality improvement projects among HIV and TB programs. We also offer recommendations for measuring quality of TB care.

Barriers and facilitators to linkage to care and ART initiation in the setting of high ART coverage in Botswana

We conducted a qualitative study using focus groups and in-depth interviews to explore barriers to and facilitators of linkage-to-care and antiretroviral treatment (ART) initiation in Botswana. Participants were selected from communities receiving interventions through the Ya Tsie Study. Fifteen healthcare providers and 49 HIV-positive individuals participated. HIV-positive participants identified barriers including stigma, discrimination and overcrowded clinics, and negative staff attitudes; personal factors, such as a lack of acceptance of one's HIV status, non-disclosure, and gender differences; along with lack of social/family support, and certain religious beliefs. Healthcare providers cited delayed test results, poverty, and transport difficulties as additional barriers. Major facilitators were support from healthcare providers, including home visits, social support, and knowing the benefits of ART. Participants were highly supportive of universal ART as a personal health measure. Our results highlighted a persistent structural health facility barrier: HIV-positive patients expressed strong discontent with HIV care/treatment being delivered differently than routine healthcare, feeling inconvenienced and stigmatized by separately designated locations and days of service. This barrier was particularly problematic for highly mobile persons. Addressing this structural barrier, which persists even in the context of high ART uptake, could bring gains in willingness to initiate ART and improved adherence in Botswana and elsewhere.

Tuberculosis and HIV Coinfection–the Challenge in the Prevention, Detection and Treatment of Tuberculosis

Background:

Tuberculosis (TB) is still a major public health concern world-wide. The increasing global burden of TB is linked to HIV infection. HIV-TB coinfection has also conditioned clinical aspects of the TB. Since the HIV is beginning in the 1980s, the HIV infection poses a significant challenge in global TB control.

Objective:

In this review we focused on the challenges of epidemiological and clinical feature of tuberculosis presented by the HIV coinfection.

Method:

The article consists of a summary of the most important effects presented by the HIV coinfection on epidemiological and clinical feature of tuberculosis. The article analyzes and summary the causes for these challenges.

Results:

The major challenges to strategy of TB control and clinical feature of TB-HIV coinfection are presented in this paper.

Conclusion:

HIV/TB co-infection is synergic, interactive and reciprocal with significant impact. The infection of HIV and Mtb affect each other and the breakdown the immune function in TB/HIV coinfected individual. HIV infection has changed the strategy of TB control, however HIV increases global burden of TB, the reduction in the TB incidence rate is far from sufficient. Atypically clinical manifestations in TB/HIV co-infected patients and increased MDR-TB and XDR-TB contribute to the challenges in the diagnosis and treatment. Increased complexity of managing patients requires expertise in the clinical m knowledge. The focused efforts to control HIV-related TB are of great urgency. These findings will provide insight into the prevention, detection and treatment of tuberculosis and will guide advances towards tuberculosis control.

Predictors of tuberculosis treatment success under the DOTS program in Namibia

OBJECTIVES

Optimal treatment success rates are critical to end tuberculosis in Namibia. Despite the scale-up of high quality directly observed therapy short-course strategy (DOTS) in Namibia, treatment success falls short of the global target of 90%. The objective of this study was to ascertain the predictors of treatment success rates under DOTS in Namibia to provide future direction.

METHODS

A nation-wide comparative analysis of predictors of treatment success was undertaken. Tuberculosis cases in the electronic tuberculosis register were retrospectively reviewed over a 10-year period, 2004-2016. The patient, programmatic, clinical, and treatment predictors of treatment success were determined by multivariate logistic regression modeling using R software.

RESULTS

104,603 TB cases were registered at 300 DOTS sites in 37 districts. The 10-year period treatment success rate was 80%, and varied by region (77.2%-89.2%). The patient's sex and age were not significant predictors. The independent predictors for treatment success as were: Region of DOTS implementation (p=0.001), type of directly observed treatment (DOT) supporter (p<0.001), sputum conversion at 2 months (p=0.013), DOT regimen (p<0.001), cotrimoxazole prophylaxis (p=0.002), and HIV co-infection (p=0.001).

CONCLUSION

Targeted programmatic, clinical and treatment interventions are required to enhance DOTS treatment success in Namibia. These are now ongoing.

ART access-related barriers faced by HIV-positive persons linked to care in southern Ghana: a mixed method study

Background

Timely and enduring access to antiretroviral therapy (ART) by HIV-infected individuals has been shown to substantially reduce HIV transmission risk, HIV-related morbidity and mortality. However, there is evidence that in addition to limited supply of antiretrovirals (ARVs) and linkage to ART in many low-income countries, HIV+ persons often encounter barriers in accessing ART-related services even in contexts where these services are freely available. In Ghana, limited research evidence exists regarding the barriers HIV+ persons already linked to ART face. This paper explores ART access–related barriers that HIV+ persons linked to care in southern Ghana face.

Methods

A mixed method study design, involving a cross-sectional survey and qualitative in-depth interviews, was conducted to collect data from four healthcare providers and a total of 540 adult HIV+ persons receiving ART at four treatment centres in Ghana. We used univariate analysis to generate descriptive tabulations for key variables from the survey. Data from qualitative in-depth interviews were thematically analysed. Results from the survey and in-depth interviews were brought together to illuminate the challenges of the HIV+ persons.

Results

All (100%) the HIV+ persons interviewed were ARV-exposed and linked to ART. Reasons for taking ARVs ranged from beliefs that they will suppress the HIV virus, desire to maintain good health and prolong life, and desire to prevent infection in unborn children, desire both to avoid death and to become good therapeutic citizens (abide by doctors’ advice). Despite this, more than half of the study participants (63.3%) reported seven major factors as barriers hindering access to ART. These were high financial costs associated with accessing and receiving ART (26%), delays associated with receiving care from treatment centres (24%), shortage of drugs and other commodities (23%), stigma (8.8%), fear of side effects of taking ARVs (7.9%), job insecurity arising from regular leave of absence to receive ART (5.3%), and long distance to treatment centres (4.9%).

Conclusions

The results in this study suggest that efforts to provide and scale-up ART to all HIV+ persons must be accompanied by interventions that address structural and individual level access barriers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2075-0) contains supplementary material, which is available to authorized users.

HIV treatment cascade in tuberculosis patients

PURPOSE OF REVIEW

Globally, the number of deaths associated with tuberculosis (TB) and HIV coinfection remains unacceptably high. We review the evidence around the impact of strengthening the HIV treatment cascade in TB patients and explore recent findings about how best to deliver integrated TB/HIV services.

RECENT FINDINGS

There is clear evidence that the timely provision of antiretroviral therapy (ART) reduces mortality in TB/HIV coinfected adults. Despite this, globally in 2013, only around a third of known HIV-positive TB cases were treated with ART. Although there is some recent evidence exploring the barriers to achieve high coverage of HIV testing and ART initiation in TB patients, our understanding of which factors are most important and how best to address these within different health systems remains incomplete. There are some examples of good practice in the delivery of integrated TB/HIV services to improve the HIV treatment cascade. However, evidence of the impact of such strategies is of relatively low quality for informing integrated TB/HIV programming more broadly. In most settings, there remain barriers to higher-level organizational and functional integration.

SUMMARY

There remains a need for commitment to patient-centred integrated TB/HIV care in countries affected by the dual epidemic. There is a need for better quality evidence around how best to deliver integrated services to strengthen the HIV treatment cascade in TB patients, both at primary healthcare level and within community settings.

The impact of flooding on people living with HIV: a case study from the Ohangwena Region, Namibia

BACKGROUND

Floods are a disaster situation for all affected populations and especially for vulnerable groups within communities such as children, orphans, women, and people with chronic diseases such as HIV and AIDS. They need functioning health care, sanitation and hygiene, safe water, and healthy food supply, and are critically dependent on their social care and support networks. A study carried out in the Ohangwena region, Namibia, where HIV prevalence is high and extensive flooding frequently occurs, aims to provide a deeper understanding of the impact that flooding has on people living with HIV (PLWHIV) as well as on HIV service providers in the region.

DESIGN

The qualitative research applying grounded theory included semi-structured interviews with PLWHIV, focus group discussions with HIV service providers, and a national feedback meeting. The findings were interpreted using the sustainable livelihoods framework, the natural hazard research approach, and health behaviour theories.

RESULTS

The study reveals that flooding poses major problems to PLWHIV in terms of their everyday lives, affecting livelihoods, work, income, and living conditions. The factors threatening them under normal conditions - poverty, malnutrition, unsafe water, sanitation and hygiene, limited access to health facilities, a weak health status, and stigma - are intensified by flood-related breakdown of infrastructure, insecurity, malnutrition, and diseases evolving over the course of a flood. A potential dual risk exists for their health: the increased risk both of infection and disease due to the inaccessibility of health services and antiretroviral treatment. A HIV and Flooding Framework was developed to display the results.

CONCLUSIONS

This study demonstrates that vulnerabilities and health risks of PLWHIV will increase in a disaster situation like flooding if access to HIV prevention, treatment, care and support are not addressed and ensured. The findings and the HIV and Flooding Framework are not specific to Ohangwena and can be transferred to any flood-affected region that has a high HIV prevalence and relies mainly on subsistence agriculture. They serve as a model case for analysing vulnerabilities related to health and health service provision under disaster conditions. The impact will vary according to the physical, geographical, climatological, social, and behavioural characteristics of the region and the people affected. In the Ohangwena region, a disaster risk management mechanism is already in place which addresses people with HIV during flooding. However, preparedness could be improved further by applying the HIV and Flooding Framework.